ASTHMA IN CHILDREN: AN UPDATE - Superior …...GINA Global Strategy for Asthma Management and Prevention 2017 This slide set is restricted for academic and educational purposes only.
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GINA Global Strategy for Asthma Management and Prevention 2017
This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA.
Asthma is a common and potentially serious chronic disease that can be controlled but not cured
Asthma causes symptoms such as wheezing, shortness of breath, chest tightness and cough that vary over time in their occurrence, frequency and intensity
Symptoms are associated with variable expiratory airflow, i.e. difficulty breathing air out of the lungs due to Bronchoconstriction (airway narrowing) Airway wall thickening Increased mucus
Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stress
Asthma can be effectively treated When asthma is well-controlled, patients canAvoid troublesome symptoms during the day and nightNeed little or no reliever medicationHave productive, physically active livesHave normal or near-normal lung functionAvoid serious asthma flare-ups (also called
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation.
It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.
Increased probability that symptoms are due to asthma if: More than one type of symptom (wheeze, shortness of breath, cough,
chest tightness) Symptoms often worse at night or in the early morning Symptoms vary over time and in intensity Symptoms are triggered by viral infections, exercise, allergen
exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smells
Decreased probability that symptoms are due to asthma if: Isolated cough with no other respiratory symptoms Chronic production of sputum Shortness of breath associated with dizziness, light-headedness or
peripheral tingling Chest pain Exercise-induced dyspnea with noisy inspiration (stridor)
1. Asthma control - two domains Assess symptom control over the last 4 weeks Assess risk factors for poor outcomes, including low lung function
2. Treatment issues Check inhaler technique and adherence Ask about side-effects Does the patient have a written asthma action plan? What are the patient’s attitudes and goals for their asthma?
3. Comorbidities Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea,
depression, anxiety These may contribute to symptoms and poor quality of life
In the past 4 weeks, has the patient had: Well-controlled
Partly controlled
Uncontrolled
• Daytime asthma symptoms morethan twice a week? Yes No
None of these
1-2 of these
3-4 of these
• Any night waking due to asthma? Yes No• Reliever needed for symptoms*
more than twice a week? Yes No• Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes• Assess risk factors at diagnosis and periodically• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessmentASSESS PATIENT’S RISKS FOR:• Exacerbations• Fixed airflow limitation• Medication side-effects
Assessment of risk factors for poor asthma outcomes
GINA 2018, Box 2-2B (4/4)
Risk factors for exacerbations include:• Uncontrolled asthma symptomsAdditional risk factors, even if the patient has few symptoms:• High SABA use (≥3 canisters/year)• Having ≥1 exacerbation in last 12 months• Low FEV1; higher bronchodilator reversibility• Incorrect inhaler technique and/or poor adherence• Smoking• Obesity, chronic rhinosinusitis, pregnancy, blood eosinophilia• Elevated FeNO in adults with allergic asthma taking ICS• Ever intubated for asthma
Risk factors for fixed airflow limitation include:• No ICS treatment, smoking, occupational exposure, mucus
The long-term goals of asthma management are1. Symptom control: to achieve good control of symptoms and
maintain normal activity levels2. Risk reduction: to minimize future risk of exacerbations, fixed
airflow limitation and medication side-effects Achieving these goals requires a partnership between patient
and their health care providers Ask the patient about their own goals regarding their asthma Good communication strategies are essential Consider the health care system, medication availability, cultural
Before starting initial controller treatment Record evidence for diagnosis of asthma, if possible Record symptom control and risk factors, including lung function Consider factors affecting choice of treatment for this patient Ensure that the patient can use the inhaler correctly Schedule an appointment for a follow-up visit
After starting initial controller treatment Review response after 2-3 months, or according to clinical urgency Adjust treatment (including non-pharmacological treatments) Consider stepping down when asthma has been well-controlled for 3
Stepwise approach to control asthma symptoms and reduce risk
GINA 2017, Box 3-5 (1/8)
Symptoms
ExacerbationsSide-effects
Patient satisfaction
Lung function
Other controller
options
RELIEVER
REMEMBER TO...
• Provide guided self-management education (self-monitoring + written action plan + regular review)
• Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
• Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of sensitizers where appropriate
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is >70% predicted
• Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised.
Step 1 It is explained that the reason ICS should be considered for
patients with mild asthma (rather than prescribing SABA alone) is to reduce their risk of serious exacerbations (Pauwels, Lancet 2003; O’Byrne AJRCCM 2001; Reddel Lancet 2017)
Steps 3-4 From the large FDA LABA safety studies: adding LABA to ICS in a
combination inhaler reduces risk of exacerbations and improves symptoms and lung function, compared with the same dose of ICS alone, but with only a small reduction in reliever use (Stempel NEJM 2016, Peters NEJM 2016)
Step 5 and Box 3-14: management of severe asthma Subcutaneous benralizumab (monoclonal anti-IL5 receptor α
antibody) is another add-on treatment for patients aged ≥12 years with severe eosinophilic asthma
Preferred option: as-needed inhaled short-acting beta2-agonist (SABA) SABAs are highly effective for relief of asthma symptoms However …. there is insufficient evidence about the safety of
treating asthma with SABA alone This option should be reserved for patients with infrequent
symptoms (less than twice a month) of short duration, and with no risk factors for exacerbations
Other options Consider adding regular low dose inhaled corticosteroid (ICS) for
Preferred option: regular low dose ICS with as-needed inhaled SABA Low dose ICS reduces symptoms and reduces risk of exacerbations
and asthma-related hospitalization and death Other options
Leukotriene receptor antagonists (LTRA) with as-needed SABA• Less effective than low dose ICS• May be used for some patients with both asthma and allergic rhinitis, or if
patient will not use ICS Combination low dose ICS/long-acting beta2-agonist (LABA)
with as-needed SABA• Reduces symptoms and increases lung function compared with ICS• More expensive, and does not further reduce exacerbations
Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with no interval symptoms
• Start ICS immediately symptoms commence, and continue for 4 weeks after pollen season ends
Before considering step-up Check inhaler technique and adherence, confirm diagnosis
Adults/adolescents: preferred options are either combination low dose ICS/LABA maintenance with as-needed SABA, OR combination low dose ICS/formoterol maintenance and reliever regimen* Adding LABA reduces symptoms and exacerbations and increases FEV1, while
allowing lower dose of ICS In at-risk patients, maintenance and reliever regimen significantly reduces
exacerbations with similar level of symptom control and lower ICS doses compared with other regimens
Children 6-11 years: preferred option is medium dose ICS with as-needed SABA
Other options Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less
effective than ICS/LABA) Adults: consider adding SLIT (see Non-pharmacological interventions) Children 6-11 years – add LABA (similar effect as increasing ICS)
Step 3 – one or two controllers + as-needed inhaled reliever
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterolGINA 2017
How often should asthma be reviewed? 1-3 months after treatment started, then every 3-12 months During pregnancy, every 4-6 weeks After an exacerbation, within 1 week
Stepping up asthma treatment Sustained step-up, for at least 2-3 months if asthma poorly controlled
• Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence)
Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen• May be initiated by patient with written asthma action plan
Day-to-day adjustment• For patients prescribed low-dose ICS/formoterol maintenance and reliever
regimen* Stepping down asthma treatment
Consider step-down after good control maintained for 3 months Find each patient’s minimum effective dose, that controls both
symptoms and exacerbations
Reviewing response and adjusting treatment
GINA 2017
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
Significant side-effects (or risk of side-effects) Significant systemic side-effects Need for oral corticosteroids long-term or as frequent courses
Symptoms suggesting complications or sub-types of asthma Nasal polyposis and reactions to NSAIDS (may be aspirin
exacerbated respiratory disease) Chronic sputum production, fleeting shadows on CXR (may be
allergic bronchopulmonary aspergillosis) Additional reasons for referral in children 6-11 years
Doubts about diagnosis, e.g. symptoms since birth Symptoms or exacerbations remain uncontrolled Suspected side-effects of treatment, e.g. growth delay Asthma with confirmed food allergy
Indications for considering referral, where available
Essential components are: Skills training to use inhaler devices correctly Encouraging adherence with medications, appointments Asthma information Guided self-management support
Self-monitoring of symptoms and/or PEF Written asthma action plan Regular review by a health care provider
Choose• Choose an appropriate device before prescribing. Consider medication options,
arthritis, patient skills and cost. For ICS by pMDI, prescribe a spacer• Avoid multiple different inhaler types if possible
Check• Check technique at every opportunity – “Can you show me how you use your
inhaler at present?”
• Identify errors with a device-specific checklist
Correct• Give a physical demonstration to show how to use the inhaler correctly• Check again (up to 2-3 times)• Re-check inhaler technique frequently, as errors often recur within 4-6 weeks
Confirm• Can you demonstrate correct technique for the inhalers you prescribe?• Brief inhaler technique training improves asthma control
Poor adherence: Is very common: it is estimated that 50% of adults and children do not
take controller medications as prescribed Contributes to uncontrolled asthma symptoms and risk of
exacerbations and asthma-related death Contributory factors
Unintentional (e.g. forgetfulness, cost, confusion) and/or Intentional (e.g. no perceived need, fear of side-effects, cultural issues,
cost) How to identify patients with low adherence:
Ask an empathic question, e.g. “Do you find it easier to remember your medication in the morning or the evening?”, or “Would you say you are taking it 3 days a week, or less, or more?”
Check prescription date, label date and dose counter Ask patient about their beliefs and concerns about the medication
Highly effective in improving asthma outcomes Reduced hospitalizations, ED visits, symptoms, night waking, time
off work, improved lung function and quality of life Three essential components
Self-monitoring of symptoms and/or PEF Written asthma action plan
• Describe how to recognize and respond to worsening asthma• Individualize the plan for the patient’s health literacy and autonomy• Provide advice about a change in ICS and how/when to add OCS• If using PEF, base action plan on personal best rather than predicted
Patients at increased risk of asthma-related death should be identified Any history of near-fatal asthma requiring intubation and ventilation Hospitalization or emergency care for asthma in last 12 months Not currently using ICS, or poor adherence with ICS Currently using or recently stopped using OCS
• (indicating the severity of recent events) Over-use of SABAs, especially if more than 1 canister/month Lack of a written asthma action plan History of psychiatric disease or psychosocial problems Confirmed food allergy in a patient with asthma
Increase inhaled reliever Increase frequency as needed Adding spacer for pMDI may be helpful
Early and rapid increase in inhaled controller Up to maximum ICS of 2000mcg BDP/day or equivalent Options depend on usual controller medication and type of LABA See GINA 2017 report Box 4-2 for details
Add oral corticosteroids if needed Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days Children: 1-2mg/kg/day up to 40mg, usually 3-5 days Morning dosing preferred to reduce side-effects Tapering not needed if taken for less than 2 weeks Remember to advise patients about common side-effects (sleep
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
ASSESS the PATIENTIs it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
MILD or MODERATETalks in phrases, prefers sitting to lying, not agitatedRespiratory rate increasedAccessory muscles not usedPulse rate 100–120 bpmO2 saturation (on air) 90–95%PEF >50% predicted or best
LIFE-THREATENINGDrowsy, confused
or silent chest
START TREATMENTSABA 4–10 puffs by pMDI + spacer, repeat every 20 minutes for 1 hourPrednisolone: adults 1 mg/kg, max. 50 mg, children 1–2 mg/kg, max. 40 mgControlled oxygen (if available): target saturation 93–95% (children: 94-98%)
CONTINUE TREATMENT with SABA as neededASSESS RESPONSE AT 1 HOUR (or earlier)
TRANSFER TO ACUTE CARE FACILITY
While waiting: give inhaled SABA and ipratropium bromide,
O2, systemic corticosteroid
URGENT
WORSENING
ARRANGE at DISCHARGEReliever: continue as neededController: start, or step up. Check inhaler technique, adherencePrednisolone: continue, usually for 5–7 days (3-5 days for children) Follow up: within 2–7 days
ASSESS FOR DISCHARGESymptoms improved, not needing SABAPEF improving, and >60-80% of personal best or predictedOxygen saturation >94% room airResources at home adequate
FOLLOW UP Reliever: reduce to as-neededController: continue higher dose for short term (1–2 weeks) or long term (3 months), depending on background to exacerbationRisk factors: check and correct modifiable risk factors that may have contributed to exacerbation, including inhaler technique and adherence Action plan: Is it understood? Was it used appropriately? Does it need modification?
IMPROVING
WORSENING
SEVERETalks in words, sits hunched forwards, agitatedRespiratory rate >30/minAccessory muscles in usePulse rate >120 bpmO2 saturation (on air) <90%PEF ≤50% predicted or best
GINA Global Strategy for Asthma Management and Prevention 2017
This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA.
Diagnosis and management of asthma in children 5 years and younger
Feature Characteristics suggesting asthmaCough Recurrent or persistent non-productive cough that may be worse at
night or accompanied by some wheezing and breathing difficulties.Cough occurring with exercise, laughing, crying or exposure to tobacco smoke in the absence of an apparent respiratory infection
Prolonged cough in infancy, and cough without cold symptoms, are associated with later parent-reported physician-diagnosed asthma, independent of infant wheeze
Wheezing Recurrent wheezing, including during sleep or with triggers such as activity, laughing, crying or exposure to tobacco smoke or air pollution
Difficult or heavy breathing or shortness of breath
Occurring with exercise, laughing, or crying
Reduced activity Not running, playing or laughing at the same intensity as other children; tires earlier during walks (wants to be carried)
Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis)Asthma in first-degree relatives
Therapeutic trial with low dose ICS and as-needed SABA
Clinical improvement during 2–3 months of controller treatment and worsening when treatment is stopped
Mainly cough, runny congested nose for <10 days; wheeze usually mild; no symptoms between infections
Gastroesophageal reflux Cough when feeding; recurrent chest infections; vomits easily especially after large feeds; poor response to asthma medications
Foreign body aspiration Episode of abrupt severe cough and/or stridor during eating or play; recurrent chest infections and cough; focal lung signs
Tracheomalacia or bronchomalacia
Noisy breathing when crying or eating, or during URTIs; harsh cough; inspiratory or expiratory retraction; symptoms often present since birth; poor response to asthma treatment
Tuberculosis Persistent noisy respirations and cough; fever unresponsive to normal antibiotics; enlarged lymph nodes; poor response to BD or ICS; contact with someone with TB
Congenital heart disease Cardiac murmur; cyanosis when eating; failure to thrive; tachycardia; tachypnea or hepatomegaly; poor response to asthma medications
failure to thrive (malabsorption); loose greasy bulky stoolsPrimary ciliary dyskinesia Cough and recurrent mild chest infections; chronic ear infections
and purulent nasal discharge; poor response to asthma medications; situs inversus (in ~50% children with this condition)
Vascular ring Respirations often persistently noisy; poor response to asthma medications
Bronchopulmonary dysplasia
Infant born prematurely; very low birth weight; needed prolonged mechanical ventilation or supplemental oxygen; difficulty with breathing present from birth
Immune deficiency Recurrent fever and infections (including non-respiratory); failure to thrive
GINA assessment of asthma control in children ≤5 years
A. Symptom control
In the past 4 weeks, has the child had: Well-controlled
Partly controlled
Uncontrolled
• Daytime asthma symptoms for more thanfew minutes, more than once/week? Yes No
None of these
1-2 of these
3-4 of these
• Any activity limitation due to asthma? (runs/plays less than other children, tires easily during walks/playing) Yes No
• Reliever needed* more than once a week? Yes No
• Any night waking or night coughing due to asthma? Yes No
B. Risk factors for poor asthma outcomesASSESS CHILD’S RISK FOR:• Exacerbations within the next few months• Fixed airflow limitation• Medication side-effects
Assess asthma control Symptom control, future risk, comorbidities
Self-management Education, inhaler skills, written asthma action plan, adherence
Regular review Assess response, adverse events, establish minimal effective treatment Record height each year, as poorly-controlled asthma may influence
growth, and ICS may be associated with growth delay in first 1-2 years Other
(Where relevant): environmental control for smoke, allergens, indoor or outdoor air pollution
Preferred option: as-needed inhaled SABA Provide inhaled SABA to all children who experience wheezing
episodes Not effective in all children
Other options Oral bronchodilator therapy is not recommended (slower onset of
action, more side-effects) For children with intermittent viral-induced wheeze and no interval
symptoms, if as-needed SABA is not sufficient, consider intermittent ICS. Because of the risk of side-effects, this should only be considered if the physician is confident that the treatment will be used appropriately.
Step 1 (children ≤5 years) – as-needed inhaled SABA
Step 2 (initial controller treatment) for children with frequent viral-induced wheezing and with interval asthma symptoms A trial of regular low-dose ICS should be undertaken first As-needed (prn) or episodic ICS may be considered The reduction in exacerbations seems similar for regular and high
dose episodic ICS (Kaiser Pediatr 2015)
LTRA is another controller option Step 3 (additional controller treatment)
First check diagnosis, exposures, inhaler technique, adherence Preferred option is medium dose ICS Low-dose ICS + LTRA is another controller option
• Blood eosinophils and atopy predict greater short-term response to moderate dose ICS than to LTRA (Fitzpatrick JACI 2016)
• Relative cost of different treatment options in some countries may be relevant to controller choices
Discuss decisions about controller treatment with parents/carers Discuss the relative benefits and risks of treatment/no treatment Emphasize the importance of maintaining normal activity levels for
normal physical and social development ICS can have a small but usually temporary effect on growth
An effect of ICS on growth velocity is seen in pre-pubertal children in the first 1-2 years of treatment
This is not progressive or cumulative [Kelly 2012, Loke 2015]. The one study that examined long-term outcomes showed a
difference of only 0.7% in adult height [Kelly 2012, Loke 2015]
Indication Asthma diagnosis, and symptoms not well-controlled on medium
dose ICS First check symptoms are due to asthma, and check adherence,
inhaler technique and environmental exposures Preferred option: continue controller treatment and refer for
expert assessment Other options (preferably with specialist advice)
Higher dose ICS and/or more frequent dosing (for a few weeks) Add LTRA, theophylline, low dose OCS (for a few weeks only) Add intermittent ICS to regular daily ICS if exacerbations are the
main problem ICS/LABA not recommended in this age group
Step 4 (children ≤5 years) – refer for expert assessment
Home management of intermittent viral-triggered wheezing Preemptive episodic high-dose episodic ICS may reduce
progression to exacerbation (Kaiser Pediatr 2016)
However, this has a high potential for side-effects, especially if continued inappropriately or is given frequently
Family-administered high dose ICS should be considered only if the health care provider is confident that the medications will be used appropriately, and the child closely monitored for side-effects
Emergency department management of worsening asthma Reduced risk of hospitalization when OCS are given in the
emergency department, but no clear benefit in risk of hospitalization when given in the outpatient setting (Castro-Rodriguez Pediatr Pulm 2016)
The development and persistence of asthma are driven by gene-environment interactions
For children, a ‘window of opportunity’ exists in utero and in early life, but intervention studies are limited
For intervention strategies including allergen avoidance Strategies directed at a single allergen have not been effective Multifaceted strategies may be effective, but the essential
components have not been identified Current recommendations are
Avoid exposure to tobacco smoke in pregnancy and early life Encourage vaginal delivery Advise breast-feeding for its general health benefits Where possible, avoid use of paracetamol (acetaminophen) and
broad-spectrum antibiotics in the first year of life